Use of Postoperative Opioid Therapy Following Endoscopic Sleeve Gastroplasty.

INTRODUCTION: There are no established guidelines on periprocedural and postprocedural pain management after endoscopic sleeve gastroplasty (ESG). This study aimed to determine the need for perioperative and postoperative opioid therapy in patients undergoing ESG. METHODS: This retrospective study comprised consecutive patients undergoing ESG. The primary outcome was the percentage of patients requiring postoperative outpatient opioid therapy. Secondary outcomes included frequency and dosage of perioperative pain medications and postoperative pain scores. RESULTS: Of the 67 patients included, 39 (58.2%) required opioids in the perioperative setting. The mean ± SD opioid dose was 12.3 ± 8.4 morphine milligram equivalents. Postoperatively, 17.9% of patients required home opioid prescriptions. More than a third of patients reported no pain. DISCUSSION: In patients undergoing ESG, postoperative opioid therapy should be individualized to attenuate opioid overprescription and the risk of opioid overuse.

Use of Impedance Planimetry in the Diagnosis of Gastric Sleeve Stenosis: The Establishment of New Benchmark Values.

INTRODUCTION: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy for which objective diagnostic criteria are lacking. Impedance planimetry measurements show promise in characterizing GSS, though normal and abnormal benchmark values have never been established. METHODS: This was a retrospective analysis of upper endoscopies performed with impedance planimetry for suspected GSS. A bariatric endoscopist, blind to impedance planimetry measurements, assessed gastric sleeve anatomy and graded GSS severity. Impedance planimetry of diameter and distensibility index (DI) were obtained using 3 different balloon volumes (30, 40, and 50 mL). RESULTS: A total of 110 upper endoscopies were included. Distribution of GSS was graded as none, mild, moderate, and severe in 19 (17%), 27 (25%), 34 (31%), and 30 (27%) procedures, respectively. In normal gastric sleeve anatomy, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. In severe GSS, mean diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±2.4) to 7.7 (±2.4), respectively. When stratified by severity, impedance planimetry measurements of diameter and DI were significantly lower with each subsequent increase in GSS grade regardless of balloon fill volumes ( P ≤ 0.001). DISCUSSION: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. A diameter ≥20 mm and a DI ≥15 mm 2 /mm Hg, as measured by impedance planimetry, are predictive of normal gastric sleeve anatomy. This study provides new benchmark values for the diagnosis and severity of GSS.

Outcomes of Cold Snare Endoscopic Mucosal Resection of Nonampullary Duodenal Adenomas ≥1 cm: A Multicenter Study.

BACKGROUND AND AIMS: Endoscopic mucosal resection (EMR) with use of electrocautery (conventional EMR) has historically been used to remove large duodenal adenomas, however, use of electrocautery can predispose to adverse events including delayed bleeding and perforation. Cold snare EMR (cs-EMR) has been shown to be safe and effective for removal of colon polyps, but data regarding its use in the duodenum is limited. The aim of this study is to evaluate the efficacy and safety of cs-EMR for nonampullary duodenal adenomas ≥1 cm. METHODS: This was a multicenter retrospective study of patients with nonampullary duodenal adenomas ≥1 cm who underwent cs-EMR between October 2014 and May 2023. Patients who received any form of thermal therapy were excluded. Primary outcomes were technical success and rate of recurrent adenoma. Secondary outcomes were adverse events and predictors of recurrence. RESULTS: A total of 125 patients underwent resection of 127 nonampullary duodenal adenomas with cs-EMR. Follow up data was available in 89 cases (70.1%). The recurrent adenoma rate was 31.5% (n=28). Adverse events occurred in 3.9% (n=5) with four cases of immediate bleeding (3.1%) and one case of delayed bleeding (0.8%). There were no cases of perforation. The presence of high-grade dysplasia was found to be an independent predictor of recurrence (OR: 10.9 [95% CI: 1.1-102.1], p=0.036). CONCLUSION: This retrospective multicenter study demonstrates that cs-EMR for nonampullary duodenal adenomas is safe and technically feasible with an acceptable recurrence rate. Future prospective studies are needed to directly compare outcomes of cs-EMR with conventional and underwater EMR.

Framework for virtual education of COVID-19 vaccines for Mandarin-speaking learners: an educational intervention module.

BACKGROUND: In the United States, patients with limited English proficiency face significant barriers to comprehending and acting upon health-related information, particularly during the COVID-19 pandemic. The ability of health professionals to communicate COVID-19-related information to Mandarin-speaking patients has proved critical in discussions about vaccine efficacy, side effects, and post-vaccine protection. METHODS: The authors created a one-hour educational module to help Mandarin-speaking medical students better convey COVID-19 vaccine information to Mandarin-only speakers. The module is composed of an educational guide, which introduced key terminology and addressed commonly asked questions, and pre- and post-surveys. The authors recruited 59 Mandarin-speaking medical students all of whom had previously completed a medical Mandarin elective. The module and surveys were distributed and completed in August 2021. Data analysis measured the change in aggregate mean for subjective five-point Likert-scale questions and change in percent accuracy for objective knowledge-based questions. RESULTS: 86.4% of participants were primary English speakers with variable levels of Mandarin proficiency. The educational module significantly improved participants' subjective comfort level in discussing the COVID-19 vaccine in English and Mandarin. The largest improvement in both English and Mandarin was demonstrated in participants' ability to explain differences between the COVID-19 vaccines, with an aggregate mean improvement of 0.39 for English and 1.48 for Mandarin. Survey respondents also demonstrated increased percent accuracy in knowledge-based objective questions in Mandarin. CONCLUSIONS: This module provides Mandarin-learning medical students with skills to deliver reliable information to the general population and acts as a model for the continued development of educational modules for multilingual medical professionals.

A case of nocardiosis in a patient with ulcerative colitis on chronic corticosteroids, infliximab, and upadacitinib.

Key Clinical Message: Immunosuppression, malnutrition, and underlying infection can unmask obscure infections which can be challenging to identify. Early diagnosis and treatment of infections in immunosuppressed patients are essential due to high morbidity and mortality. Abstract: The immunosuppressive effects of treatment for ulcerative colitis (UC), including chronic corticosteroids, anti-TNF agents, and JAK inhibitors, can impact the spread of latent or obscure infections. Clinicians should have a low threshold for pursuing aggressive diagnostic and therapeutic intervention in patients who show signs of clinical deterioration while on immunosuppressing medications. Our unique case highlights an immunosuppressed patient with UC who developed Nocardiosis after initiation of upadacitinib while hospitalized for concurrent UC flare and Clostridium difficile infection.

Evaluation of the impact of a social media-focused intervention on reducing mental health stigma among pharmacy students.

INTRODUCTION: Stigma may negatively affect the treatment of people with mental illness, and pharmacists have the opportunity to play a key role in reducing mental health stigma. The purpose of this study was to determine whether a pharmacy student-focused educational intervention impacts stigma toward people with mental illness. METHODS: A 90-minute interactive learning module, which used social media and fictional case scenarios, was developed and administered to third-year pharmacy students (n = 145) during small group class sessions. The Opening Minds Stigma Scale for Health Care Providers (OMS-HC), a validated tool to measure stigma, was administered immediately before and after the intervention. Pre-post OMS-HC scores were analyzed using related samples t tests. RESULTS: A total of 93 presurvey and postsurvey OMS-HC scores were paired and analyzed. Based on the 15-item version of the scale, stigma was significantly reduced, consistent with a score reduction of 4.6%, from 36.8 (95% confidence interval, 35.4-38.1) to 35.1 (95% confidence interval, 33.8-36.3), P < .0001. DISCUSSION: Educational interventions for pharmacy students that use social media applications might reduce mental health stigma. After the intervention, most participants believed that stigma impacts the treatment of mental illness, and that pharmacists may play a role in changing mental health stigma.

Formation, physical characteristics and microbial community structure of aerobic granules in a pilot-scale sequencing batch reactor for real wastewater treatment.

In this study, aerobic granular sludge was successfully developed in a pilot-scale sequencing batch reactor (SBR) installed on site to treat real wastewater using traditional activated sludge as inoculum. Compared with 1 or 2 months required by lab-scale reactor for aerobic granulation, it took about 400 days for activated sludge to transform into granule-dominant sludge in the pilot-scale SBR on site. Although the sludge in the reactor after 400-day operation was a mixture of flocs and granules with floc ratio ranged from 5 to 30%, sludge volume index with 5min settling (SVI5) always maintained at around 30mL/g. The similar microbial community structures represented by denaturing gradient gel electrophoresis (DGGE) between coexisted flocs and granules in the reactor indicated no strong microbial selection after the granules were dominant in the reactor. Chemical oxygen demand (COD) and NH4(+)-N removal efficiencies were above 80 and 98%, respectively, after 50-day operation, and the total inorganic N removal efficiency was about 50%. The results in this study demonstrate that it is feasible to form aerobic granules in pilot-scale SBR reactor and maintain the long-term stability of granular sludge with a high influent quality fluctuation. Meanwhile, stable COD and NH4(+)-N removal efficiencies can be obtained in the reactor.

Biodegradation of dimethyl phthalate by Sphingomonas sp. isolated from phthalic-acid-degrading aerobic granules.

Phthalic acid esters (PAEs) contamination in water, air, and soil is one of the major environmental concerns in many countries. Besides the PAE biodegradation process, the PAE degrading bacteria have become one of the focuses of study. This study reports the successful isolation of one kind of indigenous bacterium PA-02 from phthalic acid (PA)-degrading aerobic granules. Based on its 16S ribosomal DNA sequence, isolate PA-02 was identified as Sphingomonas genus with 100% similarity to Sphingomonas sp. strain D84532. Strain PA-02 was a Gram-negative, rod-shaped bacterium with strong auto-aggregation ability. In particular, the strain PA-02 possessed PAE-degrading ability without acclimation. Results of growth tests showed that strain PA-02 could degrade dimethyl phthalate (DMP), dibutyl phthalate, and diethylhexyl phthalate. The specific degradation rates of DMP and PA were concentration-dependent with maximum values of 0.4 g-DMP g(-1) biomass h(-1) and 1.3 g-PA g(-1) biomass h(-1), respectively. Kinetic studies also revealed that PA-02 was robust under high concentrations of DMP and PA. Even when the PA concentration was increased to 1,000.0 mg l(-1), the specific PA degradation rate was about 0.25 g-PA g(-1) biomass h(-1). The corresponding value for DMP was 0.067 g-DMP g(-1) biomass h(-1) at 1,000 mg l(-1).

Characteristics of aerobic granular sludge in a sequencing batch reactor with variable aeration.

Aerobic granules can be used for the treatment of industrial or municipal wastewater, but high aeration rate is required for the stable operation of the granular sludge system. Therefore, the aim of this research was to reduce aeration rate greatly to decrease the energy consumption for the technology of aerobic granules. Based on the characteristics of sequencing batch reactor with distinct feast and famine periods, aeration rate was reduced from 1.66 to 0.55 cm s(-1) in the famine period after granules were formed. It was found that the settleability of aerobic granules in reactor R1 with reduced aeration was the same as that of aerobic granules in reactor R2 with constant aeration rate of 1.66 cm s(-1). However, the outer morphology of aerobic granules gradually changed from round shape to long shape, and minor population showed certain shift after aeration rate was reduced in the famine period. Since good settleability is the most essential feature of aerobic granules, it can be said that reducing aeration rate in famine period did not influence the stable operation of aerobic granular sludge system. Furthermore, the experimental results indicated that aeration rate in feast period was much more important to the stable operation of aerobic granules than that in famine period.

Comparing activated sludge and aerobic granules as microbial inocula for phenol biodegradation.

Activated sludge and acetate-fed granules were used as microbial inocula to start up two sequencing batch reactors (R1, R2) for phenol biodegradation. The reactors were operated in 4-h cycles at a phenol loading of 1.8 kg m(-3) day(-1). The biomass in R1 failed to remove phenol and completely washed out after 4 days. R2 experienced initial difficulty in removing phenol, but the biomass acclimated quickly and effluent phenol concentrations declined to 0.3 mg l(-1) from day 3. The acetate-fed granules were covered with bacterial rods, but filamentous bacteria with sheaths, presumably to shield against toxicity, quickly emerged as the dominant morphotype upon phenol exposure. Bacterial adaptation to phenol also took the form of modifications in enzyme activity and increased production of extracellular polymers. 16S rRNA gene fingerprints revealed a slight decrease in bacterial diversity from day 0 to day 3 in R1, prior to process failure. In R2, a clear shift in community structure was observed as the seed evolved into phenol-degrading granules without losing species-richness. The results highlight the effectiveness of granules over activated sludge as seed for reactors treating toxic wastewaters.

Rapid cultivation of stable aerobic phenol-degrading granules using acetate-fed granules as microbial seed.

The aim of this study is to evaluate the utility of using aerobic acetate-fed microbial granules as a starting seed to rapidly develop stable aerobic phenol-degrading granules. Aerobic granules were first cultivated in four sequencing batch reactors with acetate as sole carbon source at a loading rate of 3.8 kg m(-3) d(-1). Phenol was then added to reactors R1, R2, R3 and R4 at loading rates of 0, 0.6, 1.2 and 2.4 kg m(-3) d(-1), respectively. The granules acclimated quickly to the phenol loading, and stabilized only 1 week after phenol was introduced. The granules exhibited good settling ability with good biomass retention and good metabolic activity, as evidenced by the low SVI values, stable biomass concentrations and good removal of acetate and phenol. No significant inhibitory effects from phenol toxicity were observed at the intermediate loadings of 0.6 and 1.2 kg phenol m(-3) d(-1), except for a slight lag in the ability of the granules to degrade phenol during the initial cycles. At the highest loading of 2.4 kg phenol m(-3) d(-1), a sharp buildup of phenol was observed in reactor R4 because the granules were initially unable to degrade phenol. However, this buildup quickly dissipated as the granules adapted rapidly to the high phenol concentrations. The compact structure of the acetate-fed granules likely protected the microorganisms against phenol toxicity and facilitated microbial acclimation towards faster phenol degradation rates. This is the first study to demonstrate the benefits of using aerobic granules cultivated on benign substrates as microbial seed to produce granules to degrade toxic substrates. This concept of using granules to produce different granules can be extended to granule-based applications involving other toxic chemicals and other types of high-strength industrial wastewaters, where rapid reactor start-up and system stability are key considerations.